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Clinical Neuroscience

JULY 30, 2020

Life threatening rare lymphomas presenting as longitudinally extensive transverse myelitis: a diagnostic challenge

TOLVAJ Balázs, HAHN Katalin, NAGY Zsuzsanna, VADVÁRI Árpád, CSOMOR Judit, GELPI Ellen, ILLÉS Zsolt, GARZULY Ferenc

Background and aims – Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports – Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion – Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.

Clinical Neuroscience

MAY 30, 2020

[Neurological aspects of the COVID-19 pandemic caused by the SARS-CoV-2 coronavirus]

BERECZKI Dániel, STANG Rita, BÖJTI Péter, KOVÁCS Tibor

[By the spring of 2020 the COVID-19 outbreak caused by the new SARS-CoV-2 coronavirus has become a pandemic, requiring fast and efficient reaction from societies and health care systems all over the world. Fever, coughing and dyspnea are considered the major signs of COVID-19. In addition to the involvement of the respiratory system, the infection may result in other symptoms and signs as well. Based on reports to date, neurological signs or symptoms appear in 30-50% of hospitalized COVID-19 patients, with higher incidence in those with more severe disease. Classical acute neurological syndromes have also been reported to associate with COVID-19. A drop in the volume of services for other acute diseases has been described in countries with healthcare systems focusing on COVID-19. During the COVID-19 epidemic it is also important to provide appropriate continuous care for those with chronic neurological disorders. It will be the task of the future to estimate the collateral damage caused by the COVID-19 epidemic on the outcome of other neurological disorders, and to screen for the possible late neurological complications of the SARS-CoV-2 coronavirus infection.]

Clinical Neuroscience

NOVEMBER 20, 2015

[Health insurance aspects of physiotherapeutic care of neurology disorders in outpatient care]

MOLICS Bálint, BONCZ Imre, LEIDECKER Eleonóra, HORVÁTH Cs. Zoltán, SEBESTYÉN Andor, KRÁNIZC János, KOMOLY Sámuel, DÓCZI Tamás, OLÁH András

[Background and purpose – The aim of our study is to analyse the ambulatory rehabilitation care of patients with neurological disorders in the field of physiotherapy. Methods – Data derive from the database of the Hungarian National Health Insurance Fund Administration (year 2009). The analyses covered patients with diagnosis „G00–G99 Diseases of the nervous system” according to the International Classification of Diseases and underwent physiotherapy treatment. Results – In 2009 altogether 190986 patients with neurological disorders received physiotherapy treatment in outpatient care, representing 1331675 cases and got 388.215 million Hungarian Forint health insurance reimbursement. The number of patients with nerve, nerve root and plexus disorders was 39 patients/10 000 population for males and 66 patients/10000 population for females. The number of patients with cerebral palsy and other paralytic syndromes was 49 patients/10000 population for males and 35 patients/10000 population for females. The number of patients with episodic and paroxysmal disorders was 33 patients/10000 population for males and 52 patients/10000 population for females. Conclusion – In the outpatient physiotherapy care the utilization indicators of females were higher in nerve, nerve root and plexus disorders and episodic and paroxysmal disorders, while in cerebral palsy and other paralytic syndromes the utilization of male was higher. There are important age and gender inequalities in the utilization of physiotherapy care of patients with neurological disorders.]

Clinical Neuroscience

NOVEMBER 30, 2019

A clinical study of an online educational programme for chronic pain patients

GALAMBOS Wellingerné Krisztina, SZOK Délia, CSABAI Márta

Background - The research of alexithymia - the inability to express or understand emotions - has recently become of great importance in clinical practice, mainly in the field of doctor-patient and psychologist patient communication. Many studies have proven the correlation between alexithymia and the development of functional somatic symptoms, i.e. somatization. Purpose - The aim of this clinical study was to examine the emotion-recognition and emotion communication patterns of patients suffering from chronic pain (e.g., headache, low back pain, arthralgia, neuropathy). Moreover, the participants received access to the Hungarian adaptation of a new international online educational site (www.retrainpain.org) dealing with pain management. Methods - Data were collected from the Headache and Chronic Pain Outpatient Clinic, Department of Neurology, Faculty of Medicine, University of Szeged, Hungary (tertiary care - Group 1) and from a general practice in district 2, Budapest, Hungary (primary care - Group 2) from March, 2017 to April, 2018. Patients received a test package containing a pain-specific questionnaire, then the Difficulties in Emotion Regulation Scale (DERS), the Toronto Alexithymia Scale (TAS-20), and the shortened Hungarian version of the WHO-Well-being (WBI-5) had to be completed. After filling out the questionnaires, all patients got access to the Hungarian adaptation of the www.retrainpain.org website. Results - Altogether 92 patients participated in the study (Group 1 n=50; Group 2 n=42). Based on the TAS-20 re­sults, 35 patients reached a pathological score (≥60 points), which indicates the diagnosis of alexithymia. The mean TAS-score was lower in Group 2 (primary care) than in Group 1 (tertiary care) (p=0.003). The DERS disclosed pathological results in 19 cases (p=0.009). As regards the www.retrainpain.org chapters, we received feedback only from 25 out of 92 patients (27%) (Group 1 n=20; Group 2 n=5). Conclusions - Although the examined patients have been suffering from different chronic pain syndromes for years and 50% of them confirmed that symptoms placed at least moderate or heavy burden on their everyday life, the available educational programme was studied only by a smaller proportion of patients than expected. Additionally, those who surveyed the Hungarian adaptation of the www.retrainpain.org website were mainly patients from primary care (Group 2), in spite of the fact that patients from specialized medical care (Group 1) had worse subjective conditions. Our future objective is to extend our database with follow-up results and to improve patients’ response willingness.

Clinical Neuroscience

JULY 30, 2019

[Treatment of complex regional pain syndrome with amitriptyline]

KOMOLY Sámuel

[Introduction - Complex regional pain syndrome is a di­stressing neuropathic pain condition without known etiology and evidence based treatment. Case presentation - Here a posttraumatic severe case of complex regional pain syndrome is presented, successfully treated by amitriptyline monotherapy. Amitriptyline is one of the most effective evidence based treatments of peri­pheral diabetic neuropathic pain and other neuropathic pain syndromes. Discussion - Amitriptyline seems to be effective to decrease pain, autonomic and motor symptoms in chronic regional pain syndrome. Conclusion - Controlled trials may be warranted to test the effectiveness of amitriptyline in complex regional pain syndrome.]

Clinical Oncology

MAY 10, 2018

[Tumor-associated neurological syndromes]

GORKA Eszter, FABÓ Dániel

[Tumor associate neurological symptoms are heterogeneous clinical entities with diverse etiologies, that may infl uence both the central, and peripheral neural system, as a primary or secondary tumor, may due to immune mediated processes. In our review, we summarize the neural syndromes frequently occurring in oncological practice. We focus on the most frequent neuronal tumors, the brain metastases, that are recently affected by the new targeted and immunotherapies showing increasing intracranial activities. We provide details on paraneoplastic neurological syndromes, because, in spite of their relatively rare occurrence, the modern diagnostic protocols may contribute to early diagnosis that are mandatory for detecting the underlying tumor. Finally we describe the neurological side effects of various oncotherapies, such as PD1 inhibitors, that are accompanied by 3% incidence of neurological complications, and chemotherapy related polyneuropathies. We provide support for anticonvulsive drug selection also, based on their drug-interaction profi le.]

Clinical Neuroscience

JULY 30, 2018

Atypical type of Hirayama disease: Onset of proximal upper extremity

AYAS Özözen Zeynep, ASIL Kıyasettin

Hirayama disease is a rare, benign motor neuron disease. It has been proposed that the dura mater’s posterior wall lacks sufficient elasticity in the lower cervical region and this causes the tense dura part to displace anteriorly upon flexion. The disease is described as involving unilateral upper extremity with a distal-onset. We reported weakness and atrophy of the proximal part of an extremity in a 45-year-old man who is diagnosed with Hirayama disease. Proximal onset is a rare type of Hirayama Disease. Clinicians must be alert of proximal involvement and the diagnosis should be confirmed with electrophysiological and flexion MRI studies.

Clinical Neuroscience

JANUARY 30, 2018

Insights into the structure and function of the hippocampal formation: Relevance to Parkinson’s disease

GYÖRFI Orsolya, NAGY Helga, BOKOR Magdolna, KÉRI Szabolcs

The link between the hippocampus and declarative memory dysfunctions following the removal of the medial temporal lobe opened unexplored fields in neuroscience. In the first part of our review, we summarized current theoretical frameworks discussing the role of hippocampus in learning and memory. Several theories are highlighted suggesting that the hippocampus is responsible for assembling stimulus elements into a unitary representation that later can be utilized to simulate future events. The hippocampal formation has been implicated in a growing number of disorders, from neurodegenerative diseases to atypical cognitive ageing and depression. Recent neuroimaging studies provided new opportunities to study in detail the hippocampal formation’s role in higher levels of the nervous system. We will present data regarding the regional specialization of the hippocampus in experimental models developed for healthy and neurological conditions with a special focus on Parkinson’s disease. Combined evidence from neuroimaging studies suggested that hippocampal volume is reduced in non-demented, newly diagnosed patients with Parkinson’s disease, which is associated with impaired memory performance. These findings proposed that, beyond the well-known striatal dopamine loss, impaired hippocampal synaptic plasticity may contribute to cognitive and affective impairments in early Parkinson’s disease.

Lege Artis Medicinae

JANUARY 20, 2018

[Depression from the aspect of polygenic studies: the role of the relationship between genes and the environment]

GONDA Xénia

[Depression is a multifactorial disease with both genes and environmental factors as well as complex relationships between these factors playing a role in its background. However, in spite of several decades of research no genetic variants playing a straightforward and robust role in the background of depression have been identified. One reason behind this is the genetic and biological heterogeneity of depression, while another is that in the majority of studies environmental effects interacting with genetic variants have not been considered which may mask important genetic effects. Furthermore, relative contribution of genetic and environmental factors may vary in case of different manifestations and subtypes of depression which has not only etiopathological relevance but may also influence choice and efficiency of treatment. Consideration of heterogeneity of depressive syndromes, as well as environmental effects in case of both candidate gene and whole genome association studies, and qualitative analysis of environmental effects in depression and antidepressant research may extend our existing knowledge concerning the pathophysiology of depression and may also aid identification of new antidepressive therapeutic targets. ]